2 Are PCTs ready to take on responsibility
for GP out-of-hours services?
11. According to the BMA, as many as 90% of GPs are
expected to opt out of providing out-of-hours cover.[10]
As PCTs take over responsibility for providing GP out-of-hours
services, they have a number of options. These include: contracting
with existing providers; inviting tenders from a range of providers,
including commercial organisations; and seeking to arrange provision
themselves, sometimes incorporating co-operatives into the PCT
organisation. In some cases, PCTs are putting in place arrangements
for the short term, pending further development of a wider model
of unscheduled care provision.
12. The NHS Confederation is an independent membership
body which is made up of the full range of NHS management across
the UK. They also led the negotiations with the BMA for the new
GMS contract on behalf of the UK Health Departments. In their
written evidence, the NHS Confederation maintained that the "necessary
structures and the support are available", and was confident
that "all primary care organisations in England, Scotland,
Wales and Northern Ireland will secure a safe and effective service
by the deadline of 1 January 2005".[11]
According to the Department's figures, many PCTs have already
taken on responsibility for GP out-of-hours services in advance
of the 31 December opt-out. Approximately 10% of PCTs took over
responsibility for out-of-hours services during April and May,
70% plan to do so between June and October, and the remaining
20% will do so in November and December. The Department argued
that local health communities have been working on the development
of out-of-hours services since the publication of the Carson Report
in October 2000. The Department has also provided support for
out-of-hours provision through a team of 14 regional co-ordinators
who have detailed knowledge of the out-of-hours field, and who
have been seconded to the Department from the NHS to provide support
to PCTs and organised providers in the implementation of the recommendations
of the Carson Report. The Department issued detailed guidance
for PCTs in October 2003. It has also subsequently provided Strategic
Health Authorities (SHAs) and PCTs with criteria which can be
used for self-assessment of the readiness of PCTs and the robustness
and sustainability of their plans.[12]
13. The Department met those SHAs and PCTs where
the opt-out was planned for April or May, and the discussions,
in the Department's view, revealed a good state of preparedness,
as well as highlighting a number of issues relating to readiness
which have informed subsequent support to PCTs. The Department
is now working with the 14 regional co-ordinators, SHAs and the
Department's Recovery and Support Unit to identify areas of concern
and, where necessary, put in place appropriate actions to ensure
an effective transition of responsibility. [13]
14. A sample of views from a survey of its members
carried out by the NHS Alliance, which is a representational organisation
for primary care and PCTs, provides a helpful snapshot of the
mixed position in different parts of the country. Below are the
views of a range of different members:
There's the makings of some sensible changes,
but there is still great risk and the PCTs do not seem to be aware
quite how fragile the situation still is.
**********
I believe out of order there is the potential
to produce chaos … The local acute trust has severe financial
pressures that have impacted on the PCTs and I feel that they
are looking to save money on out-of-hours services. I do not think
they realise what a big risk area out-of-hours services is if
it goes wrong.
**********
We have been extremely lucky in that we had a
functioning GP co-operative in situ. This had been doing 7-11pm
weekdays and weekends after 12.00 Saturdays for about seven
years. It took over the overnight sessions in January 2002 and
all out-of-hours including Saturday mornings in April 2004. We
now cover the entire PCT population with calls triaged through
NHS Direct and operate out of refurbished accommodation which
we share with the Minor Injuries Unit, a nurse practitioner led
service, at our local acute hospital. (The PCT used part of its 3
star bonus on this work.) We have been designated an Exemplar
site. Plans are well advanced to further integrate the service
with the District Nursing team and to enhance the service with
the use of Nurse Practitioners and Emergency Care Practitioners.
All the practices are enthusiastic about the levels of service
which the co-operative provides, as are the patients, and there
is a large pool of GPs willing to work the required
number of shifts. Registrar out-of-hours training is incorporated
into the process and supervised by the GP trainers on the rota.
There is a real feeling of teamwork across the district.
**********
Lots of niggles but I think they are gradually
being ironed out and I am confident that on June 1st the PCT will
be providing an out-of-hours service that is comparable to our
well respected local co-op.
**********
We are looking at a mutual organisation arising
out of the present co-op. [We have a] … small population
of 400,000 so exploring risk sharing with [another locality] to
give over 1,000,000 … Task group making progress. Hoping
to be sorted and responsibility transferred by October.
**********
Progressing steadily. Hope to outsource rather
than be run by the PCT. Local GP co-op bidding and probably the
favourite. Aim will be to have more triage than currently. Hope
to better integrate with district nurses and other teams in order
to provide a more joined up service and have less attending Accident
and Emergency (a big problem in our local area).There has been
some piloting of nurse triage at the co-op already. In middle
distance will need to work better with ambulance trust …
Hope to go live by 1st Oct or at latest 31st Oct.[14]
15. We received oral evidence from officials from
two different localities, West Hull and East Anglia, both of which
appeared to be well advanced in developing innovative solutions
to providing GP out-of-hours services for their local populations.
While we were impressed with the work being done in these two
areas, other evidence we have received does not give us confidence
that the picture of PCT preparedness is uniform across the country.
The NHS Confederation argued that "PCT readiness is not consistent
across England",[15]
and the RCGP supported this view, describing PCTs as "extremely
variable" and expressing serious doubts about the readiness
of PCTs to take on the provision of GP out-of-hours services:
From recent experience, most PCTs display a lack
of understanding of out-of-hours services issues and, in general,
are not in readiness for this responsibility. In particular, PCTs
lack understanding of GP out-of-hours issues … PCTs are also
seen as reactive rather than proactive organisations thus far,
that underestimate risks, true costs and practicalities of the
out-of-hours issue. They also generally fail to have an appreciation
of the good work done by GPs up to now.[16]
16. They also argued that few PCTs were working positively
with GP co-operatives, often instead being adversarial and generating
conflict.[17] The RCGP
went on to raise doubts about the quality of senior leadership
within many PCTs, and suggested that "currently many junior
managers and inexperienced Directors within PCTs are left to lead
on this critical issue".[18]
The BMA supported this argument, claiming that "some PCTs
have delegated out-of-hours issues to managers who do not have
the authority to make decisions, resulting in a disengagement
of stakeholders, including local GPs".[19]
17. This point was expanded upon in oral evidence
by Dr Mark Reynolds for the NAGPC:
There have been people in the PCTs taking this job
on with no experience really, thinking it is all going to be fine
and reporting up the line that everything is fine; whereas in
the other universe there are people doing the hard-edge of the
provision, knocking up against financial constraints and misunderstandings
and not confident in many areas that everything is fine.[20]
18. When we asked the Minister whether he felt sufficient
high-level management time was being invested by PCTs in GP out-of-hours
services he told us that in his view "chief executives at
PCT level" were "putting a huge amount of effort into
this".[21]
19. As well as developing a sound understanding of
the realities of delivering GP out-of-hours services and investing
this issue with sufficient priority, it is clearly also vital
that PCTs are able to look at the bigger picture of service delivery
across their areas. East Anglian Ambulance NHS Trust described
how its six PCTs have worked together collaboratively in commissioning
out-of-hours services. This has allowed economies of scale and
co-terminosity with other health and social care providers, and
eradicated many areas of duplication across PCT boundaries.[22]
However, both the BMA and the RCGP suggested that this has not
happened in every locality, arguing that rather than delivering
a cohesive approach to delivery of care for a whole city or area,
many PCTs tend to act as single units, working in a diverse way.[23]
This has meant, according to the BMA, that "some out-of-hours
services have had to deal with multiple PCTs with inconsistent
approaches".[24]
For the RCGP, this problem is underpinned by a lack of strategic
capacity within SHAs, who in their view are not working proactively
enough with PCTs to deliver whole area approaches.[25]
20. Finally, the RCGP made the point that generally
there has been little patient or user involvement in PCT discussions
over out-of-hours services and, where it exists, it is often reactive.[26]
Dr Mark McCartney, a Cornwall GP, also expressed his surprise
at the lack of public consultation about the changes to the out-of-hours
service brought about in the new GP contract.[27]
We were very pleased to hear evidence from East Anglian Ambulance
NHS Trust suggesting that they had taken steps to involve their
local population, both through consultation with the local Patient
Forum, and, more broadly, through the local Overview and Scrutiny
Committee.[28]
21. Our evidence
suggests that while PCTs across the country are in varying states
of readiness for taking on responsibility for providing GP out-of-hours
services, forward planning is taking place and support systems
are available. However, we were concerned at reports that this
critical transition was in some circumstances being managed at
too junior a level within PCTs, and also that some PCTs were failing
to think about more integrated approaches within their wider local
health economies. We urge the Department to consider these concerns
raised in our evidence in their support and management of PCTs,
and also to encourage, where possible, a greater degree of public
consultation and involvement around the redesigning of GP out-of-hours
services, as our evidence suggests that this has so far been largely
lacking.
10 Q61 Back
11
Appendix 18 Back
12
Ev 60-61 Back
13
Ev 60-61 Back
14
Appendix 22 Back
15
Appendix 18 Back
16
Ev 7 Back
17
Ev 7 Back
18
Ev 7 Back
19
Ev 4 Back
20
Q11 Back
21
Q134 Back
22
Ev 42 Back
23
Ev 7 Back
24
Ev 4 Back
25
Ev 7 Back
26
Ev 7 Back
27
Appendix 7 Back
28
Q108 Back
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